Putting NICE guidance into practice
The NHS in England and Wales is required to provide funding and resourcesfor medicines and treatments recommended by the National Institute forClinical Excellence through its technology appraisals. This is no meanfeat considering the frequency at which such guidance is published.
One health community in the south west of England — comprisingBristol, North Somerset and South Gloucestershire — has respondedto the challenge by developing a strategy that ensures NICE guidanceis implemented effectively and consistently across the region. Specifically,it has set up what it calls a NICE College to bring together all partiesinvolved in commissioning and delivery of services.
Alaster Rutherford, head of medicines management for Bristol North PrimaryCare Trust, explains that college members meet once a month and includechief pharmacists from all the acute and primary care trusts, as wellas representatives from finance, commissioning and public health.
The college examines guidance from a local perspective and requires eachhealth organisation expected to be affected by it to prepare an implementationplan. Each plan includes:
· Action needed to implement guidance
· Anticipated patient numbers
· Impact on waiting lists
· Changes in referral patterns
· Estimates of resources required over and above delivery of the existingservice
· Savings in other areas
Using estimates given within each piece of NICE guidance, PCTs agreewith their acute trust the expected level of activity for any given technology.Only technologies with a significant financial impact — over £3,000per patient per year — are monitored on an individual patient level.
Other health communities within the NHS may decide to fund the implementationof NICE guidance on a cost per case basis. “The problem with thisapproach is that trusts have to bill and PCTs have to pay for individualinterventions,” Mr Rutherford says. This, he adds, is unnecessaryand overly bureaucratic.
Mr Rutherford explains that Bristol North PCT has a number of localinitiatives designed to improve implementation of guidance. These includean incentivescheme to encourage GPs to attend educational sessions timed to linkin with the launch of NICE recommendations. For example, the Januarymeeting covered management of depression and followed a clinical guidelineon this topic published in December 2004.
Practice pharmacists provide prescribing advice to each GP practicein the PCT. They are briefed about NICE recommendations and meet GPstoagree outcome targets for guidance implementation. “In the future,I see practice pharmacists as being change agents around NICE guidance.They are the catalyst within each practice,” says Mr Rutherford.Another intervention within general practice is the inclusion of “pop-up” boxeson GP prescribing systems, to remind GPs of relevant NICE advice.
Bristol North PCT has also developed an innovative scheme within communitypharmacy to enhance awareness and implementation of NICE guidance. ThePCT has made £20,000 available annually as a competitive fundingpool to its 42 community pharmacies. To receive part of the funds, pharmaciessign up to one of three service levels, each level guaranteeing fundingof £150. The remainder is divided up at each service level anddistributed to participating pharmacies.
At the first level pharmacies must have copies of relevant NICE guidanceor guidelines. Those aiming to provide the third level must conduct anaudit around a piece of guidance. One area in which the PCT was keenfor an audit to be completed was around use of cyclo-oxygenase-2 (COX-2)inhibitors. Community pharmacists reviewed NICE guidance relating touse of these drugs and identified patients presenting with prescriptionsfor COX-2 inhibitors plus aspirin and contacted patients’ GPs.
In addition to these initiatives, Mr Rutherford also ensures that awarenessof NICE guidance is raised among pharmacists through continuing educationworkshops. In his role as a tutor for the Centre for Pharmacy PostgraduateEducation he links workshops with guidance. “We are trying subtlyto get everyone up to speed on the most important clinical guidelines,including those for chronic obstructive pulmonary disease and heart failure.”
The effects of these initiatives, as a whole, can be significant. MrRutherford points out that local prescribing of COX-2 inhibitors hasbeen half that of the national average. “The initiatives are aboutpromoting an escalator of excellence,” he says.
The introduction of “Payment by results” in April (when settariffs for treatment will free PCTs from price negotiations) will changethe focus of the NICE College, explains Mr Rutherford. “Up untilnow, the focus of the college has been driven by the allocation of resources.”
Payment by results will see an increase in the amount of money availableto fund treatments covered by new NICE guidance. This means the collegewill be able to concentrate on quality and clinical governance — makingsure patients are receiving the treatments they need — rather thanon whether there is funding available.
In addition to this move, Mr Rutherford believes there needs to be abrutal analysis of how illnesses are managed. “We have newer treatmentsavailable for patients with worsened conditions. Do we necessarily stillneed the infrastructure that has been in place for dealing with thatcondition? Therapeutic advances may shift patient care away from hospitalbeds and into communities. Has the overall team approach changed to accommodatethis,” he asks.
He also believes that implementation of NICE clinical guidelines presentsa challenge. There is no statutory obligation to fund the guidelinesbut their implementation is included as a developmental standard withinthe Department of Health’s “Standards for better health” documentpublished last year. “Health communities should be planning howthey are going to tackle this,” says Mr Rutherford, warning: “Thething about developmental standards is that they tend to become obligatory.”
The initiatives introduced by this health community mean that strongerworking relationships now exist between organisations and duplicationof work across PCTs has been reduced. And there are now robust, long-termprocesses in place for implementing NICE guidance.
Citation: The Pharmaceutical Journal URI: 10018068
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